Continuing medical education
What's new: Management of venous leg ulcers: Approach to venous leg ulcers

https://doi.org/10.1016/j.jaad.2014.10.048Get rights and content

Leg ulcerations are a common problem, with an estimated prevalence of 1% to 2% in the adult population. Venous leg ulcers are primarily treated in outpatient settings and often are managed by dermatologists. Recent advances in the diagnosis and treatment of leg ulcers combined with available evidence-based data will provide an update on this topic. A systematized approach and the judicious use of expensive advanced therapeutics are critical. Specialized arterial and venous studies are most commonly noninvasive. The ankle brachial pressure index can be performed with a handheld Doppler unit at the bedside by most clinicians. The vascular laboratory results and duplex Doppler findings are used to identify segmental defects and potential operative candidates. Studies of the venous system can also predict a subset of patients who may benefit from surgery. Successful leg ulcer management requires an interdisciplinary team to make the correct diagnosis, assess the vascular supply, and identify other modifiable factors to optimize healing. The aim of this continuing medical education article is to provide an update on the management of venous leg ulcers. Part I is focused on the approach to venous ulcer diagnostic testing.

Introduction

Leg ulcers are a common problem, with an estimated prevalence of 1% to 2% in the adult population, similar to the prevalence of psoriasis and alopecia areata.1, 2, 3 With shifting demographics toward an aging population, sedentary lifestyles, an increased prevalence of obesity, and the emergence of various chronic diseases, leg ulcers will likely continue to be a significant burden on the health care system.4, 5 Despite the myriad potential causes of leg ulcers, a majority are caused by vascular abnormalities, with venous disease being the most common cause. Recent advances in the diagnosis and treatment of leg ulcers combined with the latest available evidence indicate a need for an update on this topic. A systematized approach and the judicious use of advanced expensive therapeutics are critical. The aim of this continuing medical education article is to provide an update on venous leg ulcers (VLUs). Part I is focused on the diagnostic approach to VLUs. In part II, the current medical and surgical management options will be reviewed.

Section snippets

Epidemiology

Key points

  1. Approximately 1.5 to 3 per 1000 adults have active leg ulcers in North America

  2. Venous leg ulcers are more common in elderly patients, but 22% of individuals develop their first venous leg ulcers by 40 years of age, and 13% by 30 years of age

The overall incidence of venous disease has been documented to be 76.1 per 100,000 person-years.6 It is estimated that approximately 1.5 to 3 per 1000 North American adults have active leg ulcers.7 Although chronic leg ulcers may be caused by many

Pathogenesis of venous disease

Key point

  1. Valve dysfunction, outflow obstruction, arteriovenous malformation, and calf muscle pump failure contribute to the pathogenesis of venous disease

The venous system is constructed like a ladder, with deep and superficial veins forming the 2 sides connected by perforator veins as the rungs (Fig 1). The calf muscle pump acts as a “peripheral heart,” propelling venous blood toward the heart during calf muscle pump contraction. Unidirectional valves in the vein allow blood flow in 1 direction toward

Approach to venous leg ulcers

Key points

  1. A comprehensive history and physical examination are essential in the evaluation of chronic venous insufficiency and ulceration

  2. Varicose veins in the medial thigh and calf may implicate involvement of the great saphenous vein; dilated veins in the anterolateral thigh and knee are related to anterior saphenous insufficiency

A comprehensive history and physical examination are required for an accurate diagnosis (Fig 6). Information should include symptoms, exacerbating and alleviating factors,

Vascular assessment: Arterial and venous

After a comprehensive clinical assessment, subsequent noninvasive and sometimes invasive investigations may be indicated to confirm the diagnosis and plan treatment options. Assessment of the arterial system to rule out mixed arteriovenous disease is important. Up to 25% of patients with a VLU have concomitant peripheral arterial disease.59, 60

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    Funding sources: None.

    Dr Kirsner is an advisory board member of 3M, KCI, Keraplast, Kerecis, and Mölnlycke, and is an investigator for Macrocure and Smith & Nephew. Dr Margolis is an advisory board member of Kerecis. Dr Alavi is an advisory board member for AbbVie, Janssen; an investigator for AbbVie, Novartis, and Xoma; and received a grant from AbbVie. The other authors have no conflicts of interest to declare.

    Date of release: April 2016

    Expiration date: April 2019

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